Signs and Symptoms of Cholecystitis
The classic presentation of acute cholecystitis includes right upper quadrant pain, fever, nausea, vomiting, and anorexia, with physical examination revealing right upper quadrant tenderness. 1, 2, 3
Clinical Presentation
Cardinal Signs and Symptoms
- Right upper quadrant pain: Most consistent symptom
- Murphy's sign: Focal tenderness when pressing on the right upper quadrant during inspiration
- Fever: Often low-grade but can be higher in complicated cases
- Nausea and vomiting: Common accompanying symptoms
- Anorexia: Decreased appetite frequently reported
Additional Clinical Findings
- Abdominal distension
- Jaundice (may be present in cases with bile duct obstruction)
- Choluria (dark urine) and fecal acholia (pale stools) if biliary obstruction occurs
- Pruritus (in cases with cholestatic jaundice)
Diagnostic Evaluation
Laboratory Findings
- Leukocytosis (elevated white blood cell count)
- Elevated liver function tests:
- AST and ALT (may be mildly elevated)
- Alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT)
- Direct and indirect bilirubin (especially in obstructive cases)
- Inflammatory markers: Elevated C-reactive protein (CRP)
- In critically ill patients: Elevated procalcitonin (PCT) and lactate may indicate severity 1
Imaging Studies
Ultrasound (First-line imaging)
- Sensitivity: ~81%, Specificity: ~83% 2, 3
- Key findings:
- Gallstones (96% accuracy for detection) 1
- Gallbladder wall thickening (>3mm)
- Pericholecystic fluid
- Sonographic Murphy's sign (tenderness when probe is over gallbladder)
- Gallbladder distension
Hepatobiliary Scintigraphy (HIDA scan)
- Gold standard when ultrasound is inconclusive
- Higher sensitivity (97%) and specificity (90%) than ultrasound 1, 2
- Non-visualization of gallbladder indicates cystic duct obstruction
CT Scan
- Useful for detecting complications
- Findings include:
- Gallbladder wall thickening
- Pericholecystic fluid
- Gallbladder distension
- Adjacent liver parenchymal hyperemia
MRI with MRCP
- Recommended for detecting cholelithiasis/choledocholithiasis
- Sensitivity of 85-100% 2
Complications of Cholecystitis
Severe Complications
- Gangrenous cholecystitis: Necrosis of gallbladder wall due to ischemia
- Emphysematous cholecystitis: Gas-forming infection in gallbladder wall
- Gallbladder perforation: Can lead to localized abscess or diffuse peritonitis
- Hemorrhagic cholecystitis: Bleeding into gallbladder lumen
- Biliary peritonitis: From gallbladder perforation
Chronic Sequelae
- Recurrent cholangitis
- Bile duct strictures
- Secondary biliary cirrhosis (in long-standing cases)
- Portal hypertension
- Liver failure
Management Approach
Initial Management
- Fluid resuscitation: Normal saline or lactated Ringer's at 10 ml/kg/hour 2
- NPO (nothing by mouth)
- Pain management: NSAIDs as first-line therapy 2
- Antibiotic therapy:
- First-line: Amoxicillin/Clavulanate
- Alternatives: Ceftriaxone + Metronidazole, Ciprofloxacin + Metronidazole 2
Definitive Treatment
- Early laparoscopic cholecystectomy (within 72 hours of diagnosis) is the gold standard treatment 2, 3
- Benefits include:
- Lower recurrence rates
- Shorter hospital stays
- Lower costs
- Lower mortality (especially in elderly patients) 3
Alternative Treatments
- Percutaneous cholecystostomy: For high-risk patients unfit for surgery 2, 4
- Should be considered a bridge to surgery rather than definitive treatment
- Associated with higher complication rates (65%) compared to laparoscopic cholecystectomy (12%) 3
Special Considerations
- Acalculous cholecystitis: Occurs in 5-10% of cases, typically in critically ill patients 3
- Pregnancy: Early laparoscopic cholecystectomy is recommended during all trimesters 3
- Elderly patients: Laparoscopic cholecystectomy associated with lower 2-year mortality (15.2%) compared to nonoperative management (29.3%) 3
Remember that early diagnosis and appropriate management are crucial to prevent complications and improve outcomes in patients with acute cholecystitis.